Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis

The nursing process provides a clinical decision-making framework for patients and families to establish and implement a personalized care plan. Since part of the nurse's duties is to teach patients, the steps of the nursing process are the most effective way to approach instruction. The nursing process and the teaching-learning process are inextricably linked.

It is critical to determine the patient's learning needs during the assessment. Determination of learning needs compounds data from the patient or their medical record. Data is also collected from the patient's families when the patient cannot communicate. Four factors must be considered when analyzing the patient's or caregiver's learning needs.

• • First, identify their knowledge, abilities, or attitudes needed to manage healthcare independently.
• • Second, assess their readiness to learn. Learning readiness can involve emotional preparedness, such as mental health, or experiential readiness, such as previous experiences.
• • Third, evaluate their learning abilities, such as literacy level.
• • Finally, recognize their learning strengths, such as strong motivation or psychomotor abilities.

A diagnosis is developed upon assessing the patient's learning needs. A diagnosis is a clinical judgment about a patient that aids in setting and prioritizing goals. The nurse identifies a deficiency if the patient lacks the knowledge, attitudes, or abilities to enhance health promotion. When identifying learning requirements, reference North American Nursing Diagnosis Association (NANDA) approved diagnoses or problem statements. For example, a self-care deficit related to a stroke diagnosis: the related factor presents a problem on which the teaching strategy is planned.